Name
Registered Mobile Number
Select Dental problem for which you consulted us?
Pain in wisdom toothPain in toothPain in GumsPain in Mobile toothSensitivityBad breathBleeding gumsRoot Canal TreatmentMissing toothDental Implantswollen gumTooth fillingulcerswelling on faceBracesOrthodontic treatmentOther
Overall do you see improvement after
taking treatment/ consultation from us?
YesNO
Does your problem settled for which you
took Dental treatment/consultation?
Message for the team/ any info you want to share
